Fat embolism in right internal jugular vein: incidental ultrasound finding during internal jugular vein cannulation

Abstract

Background We report a case study of fat embolism seen on ultrasound at right internal jugular vein during central venous cannulation in a patient diagnosed with fat embolism syndrome. This case demonstrates the importance of ultrasound for evaluation of trauma cases with suspicion of fat embolism. Case presentation A 23-year-old trauma patient with closed fracture of left femoral shaft and left humerus presented to our emergency department (ED). 11 h after admission to ED, patient became confused, hypoxic and hypotensive. He was then intubated for respiratory failure and mechanically ventilated. Transesophageal ultrasound revealed hyperdynamic heart, dilated right ventricle with no regional wall abnormalities and no major aorta injuries. Whole-body computed tomography was normal. During central venous cannulation of right internal jugular vein (IJV), we found free floating mobile hyperechoic spots, located at the anterior part of the vein. A diagnosis of fat embolism syndrome later was made based on the clinical presentation of long bone fractures and fat globulin in the blood. Despite aggressive fluid resuscitation, patient was a non-responder and needed vasopressor infusion for persistent shock. Blood aspirated during cannulation from the IJV revealed a fat globule. Patient underwent uneventful orthopedic procedures and was discharged well on day 5 of admission. Conclusions Point-of-care ultrasound findings of fat embolism in central vein can facilitate and increase the suspicion of fat embolism syndrome. Electronic supplementary material The online version of this article (10.1186/s13089-019-0116-9) contains supplementary material, which is available to authorized users.

Diagnosis of fat embolism syndrome using point‐of‐care ultrasound

“…17 Ultrasonography has also been used to detect floating mobile hyperechoic spots in internal jugular veins of patients diagnosed with FES. 1 Transcranial Doppler (TCD) has been described as an interesting diagnostic tool, as it can detect MES caused by moving microemboli. MES are characterized by large-amplitude, unidirectional, transient signals lasting less than 300 ms, with a chirping or clicking sound.…”

“…Transthoracic and transesophageal echocardiography can detect fat emboli during orthopaedic surgery as hyperechoic particles in the cardiac cavities 17 . Ultrasonography has also been used to detect floating mobile hyperechoic spots in internal jugular veins of patients diagnosed with FES 1 . Transcranial Doppler (TCD) has been described as an interesting diagnostic tool, as it can detect MES caused by moving microemboli.…”

“…If symptomatic, it can result in severe damage to vital organs and even death. Diagnosis of FES remains a challenge for clinicians due to the multiple diagnostic criteria available 1 . Microemboli detection is a well‐known method frequently employed in transcranial Doppler (TCD) studies 2 .…”

Incidence of Fat Embolism Syndrome in Femur Fractures and Its Associated Risk Factors over Time—A Systematic Review

“…Fat embolism syndrome (FES) continues to be mentioned in the current literature as a potentially devastating complication following orthopedic trauma involving long-bone fractures. Although the triad of hypoxia, petechial rash, and altered mental status appears to be less common, the concern among surgeons continues to be relevant [ 40 ].…”